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17B-013 (3) • O4(tSAa1P1O .. Lif-P of Nart4aiitptan L r � � jlxlassaclTuseffs = M DEPARTMENT OF BUILDINTG INSPECTIONS INSPECTOR 212 Main Street • Municipal Building s , Northampton, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as iris/her construction sups;:, sor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a home owner." The building department for the City of Northampton wants any person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called tG inspect-wo&atvarious-stages,which.include-fo-und -fw-uLfootings_(before backfill), sonotube holes (before pour), a rough building inspection(before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancv until the work can be inspected. If the homeowner hires other trades to perform work(electrical, plumbing& gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date e�C7-e)ee< Address of work locationg'Y i pTO (riff efTarfllailt toll w o DEPARTMENT OP DUILDfNG INSP-ECrION'S 212 Main Street Nfunieipal Building Northampton, 7fass. 01060 «`OPICER'S C06[PENSATION MSURANCE A �Tj- \kqth a piulcipal place of business/residence at: ye,-",V,tf hone.') S�c f=S`27yS� (suit/ci rJ/sta.u•�n p) do hereby certify, under dic.pains tad penalties of pcgufy, hal ( ) I am an employer providing the followinQ, %vorkcr's colnoensaZ ion cove—,fie Lor Iny etuplovees worUng on tills job: (Insl=an= (PoLic; Nu--Lb--r) -- (-_,pirrvoa Dais.) O I am a sole propretor, general contractor or homeoWoer (ci:cie or!e) and have hired the cons;actors GSted below wbo have the Eoilotvine worke>'s coecensation pakies: (N al-Ac oT COnmlci0') (lIl_�t!raI1C„. COtTIDJJ"1}'lPGUCi }�tt1II'1.C) (f_J:Jt,'J�^i? DaIC) -- (Name of Coacraaor) (1rj-S-u=c: ComoaaviPa!—v Nuns-:r) (xpir boa Date) (Name of Conrraeto:) Cuisuranc Compa-o)•/Poliq- N-,unb,-r) (Expirtion Date) (Na-me of Contractor) as urmcc ComrznY1,Poticy Nu-mb:r) (Expiation Daft). (na,c:r �'od�cC,ifncec�iry cn me in.formi'ioo pctaini.as in all Doer-_c_.o�) 7 { ) I am a sole proprietor and bave no one wor4,-ing for me. I am.a home owner performing all the work myself. NOTE:plebe be 'tEjc bcmcow-acr,wbo csploy,per oc=to dz m.m p:w wori;oa c d.•cll_^.Z of aot more tb_n thoe U=L%is uiich Fbc boca�raider or oc the aouzx,zgpurtcnuI=L tbe-Gn c c oc(C= ally co=daai to fti eitplOr--,11 the lea Act(GL151 —t(5)�>4>plic1.6ca by a bomma-.a far c lied__cc pc-scut ray C"6=e the 1c- rta.a.of ca crPtayx reader d-W",e,Coo,pamacio Act I yadcziand d14 a ooyy of tbi.mtemcm o y bo F.--,id d to tba p , of In�.,�sr;.J Read Offioo of 4—,- roc Uh oovatbc vc Gcaioa`ad tlu Ld=c w rcouc tovcr&&�t c+ r!oc Oa 25 A of),(GL 152 na I¢d to the iaposaioa of cimin,!pmat - -i:lag or a fine or up to S I-300.00 uNor ar� of up to Doc y,rid ci,J pca&tia in do form of a S'wp Wort;OH aad a Ci=of S 100.00 a d_ pic-a t� For d puuxa=-�u+c only ��^ E'C7 In11 �l1IIlt)CS Lot " S i g=ltun of Lic=sce ,,rni uec 1 k SECTION 8-CONSTRUCTION SERVICES' 8.1 Licensed Construction Supervisor. Not Applicable ❑ Name of License Holder License Number Address Expiration Date -Signature �> Telephone 9=R'e°a s t e f e"c i F f o m e i f i i t p"r o u e i n e n t C a%� s q � - Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10=WORKERS'COMPENSATION INSURANCE 'F (M.G:L..c.1"52;§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... ❑ No...... ❑ The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.CMR 780. Sixth Edition Section 108.3.5.1. Definition of Homeowner:Per-son-(s)-who-awn-a-parcel ofland on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153(Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,State and Local Zonin aws and Sta�4 assachusetts General Laws Annotated. Homeowner Signature T, SECTION 5--DESCRIPTION OF PROPOSED-WORK(check>all applicable) New House ❑] Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑ Or Doors 13 Accessory Bldg. '�V Demolition ❑ New Signs [0] Decks (p Siding[O] Other(0] Brief Description of Proposed /� Work: 167 A t(CEO w COD P Alteration of existing boom Yes _No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes X No Plans Attached Roll -Sheet 6aij.E New.Eto�ts�ar c .oaddcan� cex>I #FEaoc'sEtcarnlaEefaEEQyg: a. Use of building: One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No. 1. Septic Tank . City Sewer Private well City water Supply SECTION 7a,--OWNER AUT-HQRIZATION-TO BE CGMPLE-T-ED=.VVHEM7 OWNERS:AGENTORS C011TRiACTOR:APPLIES.FOR'BUILDIN.G P.,ERMIT 1, as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, Owner uthorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to th of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name Signature of Owner/Agent Date or Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front 0 AA- Rear Building Height 7 Bldg.Square Footage - % Open Space Footage % (Lot area minus bldg&paved zss parking) z #of Parking Spaces IF- ^ � � ' A. Has a Special Perm/t/Vahunoe/Finding ever been issued for/on the site? � �� � NO ^�� DON'T KNOW YES IF YES, date issued: IF YES: Was the permit veoundod at the Registry ofDeeds? NO `~^� ) DONT KNOW -- IF YES: enter Book Page! and/or Document � B. Does the site contain u brook, body uf water urwetlands? NO �~��v DON7KNOVV YES �= IF YES, has a permit been or need tube obtained from the Conservation Commission? Needs tobeobtained ' �~� Obi �`� Date Issued: �~� t~~/ ' C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 N0 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,gradiexcavation,or filling)over 1 acre nris it part o[a common plan that will disturb over 1 acre? YEG [ l NO y�) �� IF YES,then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton s p Building Department 212 Main Street s�treazi� d Room 100 a ., MI.Northampton, MA 01060 itstrra > ao"YU �gzn * r a _ phone 4'13-5.87-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION,1;-SITEaNFORMATION' This°section to-,be dffipI-0- by°�ffice 1.1 Property Address.r 01 dr/ Gn r 1001014 a Lot Unrt fi�OO�,Lc/K"C �f�s.� Zak O�eria�D�tcrct,e Etitz St distrrcL 21 SECTIONr 2.-PROPERTY'OWNERSHIPIAUTHORIZED AGENT- 2.1 Owner of Record: Name(Print) Current Mailing Address: Telephone ,cgs-_ S" 5/ Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATEDYCONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant _- 1. Building /{ (a)Building Permit Fee 2. Electrical (J ;(by.Estimated Total Cost of Construction.from'6' 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number Q This Section:For Official Use Only Date Building.,Permit Number.: Issued: Signature: Building Commissioner/Inspector of Buildings Date •Y'O.ffjjy dam;�O<�/t / a o ea�dd S t© 42 T e_� kf.A(L i C R Y dw G c edli File#BP-2007-0440 APPLICANT/CONTACT PERSON BENOIT PAULA M&JOHN ADDRESS/PHONE 384 BRIDGE RD FLORENCE (413)585-5845 () PROPERTY LOCATION 384 BRIDGE RD MAP 17B PARCEL 013 001 ZONE RR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid gpoco Typeof Construction: ERECT 10 X 16 PIGEON COOP New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/Statement or License 3 sets of Plans/Plot Plan THFpproved LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INATION PRESENTED: Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* _ Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commi n /d 1cY1,6 Signature of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning&Development for more information. 384 BRIDGE RD BP-2007-0440 GIs#: COMMONWEALTH OF MASSACHUSETTS Map.Block: 17B-013 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category_ BUILDING PERMIT Permit# BP-2007-0440 Project# JS-2007-000653 Est.Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Groin Homeowner as Contractor Lot Size(sq. ft.): 9408.96 Owner: BENOIT PAULA M&JOHN Zoning: RR Applicant: BENOIT PAULA M & JOHN AT. 384 BRIDGE RD Applicant Address: Phone: Insurance: 384 BRIDGE RD (413) 585-5a45-0 FLORENCEMA01062 ISSUED ON.1012012006 0:00:00 TO PERFORM THE FOLLOWING WORK.-ERECT 10 X 16 PIGEON COOP POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 10/20/2006 0:00:00 $25.00107876 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo